Provider Demographics
NPI:1366787210
Name:MIKOTTIS, MARY JO (APN)
Entity type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:MIKOTTIS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 E BRUSH HILL RD
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-5658
Mailing Address - Country:US
Mailing Address - Phone:331-221-0560
Mailing Address - Fax:331-221-3833
Practice Address - Street 1:155 E BRUSH HILL RD
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-5658
Practice Address - Country:US
Practice Address - Phone:331-221-0560
Practice Address - Fax:331-221-3833
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.008073364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist